Faculty Bibliography

OBJECTIVES/HYPOTHESIS: This study investigated the differences between the standard guidelines and the practice patterns of otolaryngologists in managing "penicillin-allergic" patients. A major goal was to identify factors influencing an otolaryngologist's choice of antibiotic. STUDY DESIGN: Cross-sectional survey. METHODS: Four hundred seventy members of the American Society of Pediatric Otolaryngologists (ASPO) and 150 general otolaryngologists from the Florida Society of Otolaryngology (FSO) were surveyed. RESULTS: Ninety-six ASPO members (20.4%) and 22 members of FSO (14.6%) responded. When asked about the management of a pediatric patient with acute otitis media and a history of a nonsevere immunoglobulin E (IgE)-mediated amoxicillin allergy, 54% of ASPO respondents indicated they would initiate guideline-recommended cefdinir, whereas only 27% of FSO respondents chose cefdinir (P = .02). Otolaryngologists who are fellowship trained in pediatrics or have pediatric-focused practices were significantly more likely to prescribe cefdinir. Overall, 57% of respondents indicated that they were familiar with the literature regarding the cross-reactivity of beta-lactams, but only 25% of respondents felt that they could easily differentiate a potentially life-threatening IgE-mediated allergy from a non-IgE-mediated drug intolerance. CONCLUSIONS: The data show differences between the current recommendations and the behavior of otolaryngologists. Pediatric otolaryngologists were more familiar with the guideline-recommended therapy, likely from their frequent exposure to patients requiring a beta-lactam. Nevertheless, most otolaryngologists could benefit from increased awareness of the current literature. Patients may be receiving less than optimal medication management due to a misidentification of those at risk of life- threatening allergic cross-reactions. LEVEL OF EVIDENCE: NA Laryngoscope, 2015.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. OBJECTIVE: The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. METHODS: We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. RESULTS: Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). CONCLUSION: A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.

Motion sickness can be a limiting factor for sea and air missions. We report the experience of a Pararescue (PJ) team on a Pacific Ocean rescue mission in which motion sickness was prevalent. Cinnarizine, an antagonist of H1-histamine receptors, was used to treat affected PJs. We also report findings of a survey of PJs regarding motion sickness. A family of four on a disabled sailboat 900 miles off the coast of Mexico sent out a distress call because their 1-year-old daughter became severely ill with fever and diarrhea. Four PJs were deployed on a C-130, performed a free-fall parachute insertion into the ocean, and boarded the sailboat. All four PJs experienced onset of motion sickness at some point during the early part of the mission and symptoms persisted through the first 24 hours. Three PJs experienced ongoing nausea, vomiting, dizziness, and sensory imbalances. The captain of the sailboat offered the three sick PJs approximately 18mg of cinnarizine two or three times a day with relief of symptoms and improvement on operational effectiveness. A new, anonymous, voluntary survey of Air National Guard PJs and combat rescue officers revealed that 78.4% of Operators have experienced motion sickness at sea. We discuss the current theories on motion sickness, the effect of motion sickness on operational effectiveness, and research on treatment of motion sickness, including the medication cinnarizine.

OBJECTIVE: To determine the prevalence of otolith dysfunction in patients with refractory benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Unmatched case control. SETTING: Tertiary care institution. SUBJECTS AND METHODS: Patients included were diagnosed with BPPV, failed initial in-office canalith repositioning maneuvers (CRMs), and completed vestibular testing and vestibular rehabilitation (n = 40). Refractory BPPV (n = 19) was defined in patients whose symptoms did not resolve despite vestibular rehabilitation. These patients were compared with a control group of those with nonrefractory BPPV (n = 21) for results of a caloric test, cervical vestibular evoked myogenic potential (cVEMP), and subjective visual vertical (SVV). RESULTS: Forty-six of 251 patients failed initial treatment with in-office CRM. Forty patients met inclusion criteria. There was no significant difference between the cases (refractory BPPV) (n = 19) and controls (nonrefractory BPPV) (n = 21) in terms of age, duration of symptoms, laterality of BPPV, and BPPV symptoms. There was no difference in the prevalence of caloric weakness and cVEMP abnormalities (P > .05), with odds ratios (ORs [95% confidence interval (CI)]) of having abnormal results among cases vs controls of 1.1818 (0.3329-4.1954) and 4.3846 (0.7627-25.2048), for caloric and cVEMP, respectively. Abnormal eccentric SVV was more prevalent in refractory BPPV cases (58%) than in controls (14%) (P < .0072). The OR (95% CI) of having abnormal SVV was 8.25 (1.7967-37.8822) higher among patients with refractory BPPV than those with nonrefractory BPPV. CONCLUSION: Patients with refractory BPPV are more likely to have abnormal eccentric SVV and thus underlying utricular dysfunction. This finding is important to take into account when designing rehabilitation strategies for patients with BPPV who fail CRM.

Objective: To assess the complication and migration rates associated with fixation of cochlear implant receiver stimulators using a subperiosteal tight pocket without either suture fixation or bone recession. Study Design: Dual institution retrospective case review Methods: A retrospective case review was conducted at two tertiary referral centers. All patients who underwent cochlear implantation with device fixation using a subperiosteal tight pocket without suturing over the device or recessing of the receiver stimulator in bone were identified. There was a minimum follow-up period of six months. Outcome measures included intraoperative and postoperative complications, including evidence of device migration associated with interference with external device use or need for revision surgery. Other outcome measures included soft tissue flap complications. Results: Sixty-two patients were identified with a mean age of 39 years, (range 1.5-95 years). The average follow-up period was 32.6 months (range 6-120 months). Device manufacturers included Cochlear Corporation (n=44), MED-EL (n=12) and Advanced Bionics (n=6). There were no associated intraoperative complications related to subperiosteal pocket fixation of the receiver stimulator, and no cases of migration were identified. Conclusion: Fixation of the cochlear implant receiver stimulator using a subperiosteal tight pocket without either suture fixation or bone recession has been demonstrated to be feasible across a range of patient demographics and cochlear implant devices. This method of fixation appears to allow for an efficient and minimally invasive approach without compromising patient safety or device performance.

OBJECT: The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.). METHODS: The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded. RESULTS: Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction). CONCLUSION: Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization.

Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB >2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p < 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB > 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve can be a valuable adjunct to conventional facial nerve electromyography during resection of tumors at the CPA. Intraoperative deltaTCMEP >57 V may be worrisome for long-term recovery of satisfactory facial nerve function.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy of image-guided surgical navigation (IGSN) in otologic surgery and establish practice guidelines. STUDY DESIGN: Prospective study. METHODS: Between January 2003 and January 2010, all patients requiring complicated surgery for chronic otitis media, glomus jugulare, atresia, cerebrospinal fluid leak with or without encephalocele, and cholesterol granuloma of the petrous apex were offered IGSN. The accuracy of IGSN relative to pertinent pathology and 11 anatomic landmarks was established. Additionally IGSN-related operative time, complications, and surgical outcome were recorded. RESULTS: In the study period there were 820 otologic procedures, among 94 patients (96 ears) with disease meeting proposed criteria. Thirteen patients (15 procedures) consented to the use of IGSN. All patients had a minimum 6 months of follow-up. The average additional operative time required was 36.7 minutes. The mean accuracy error was 1.1 mm laterally at the tragus but decreased to 0.8 mm medially at the level of the oval window. The mean accuracy of IGSN was within 1 mm in 10 of the 11 targeted surgical anatomic landmarks. CONCLUSIONS: Interactive image-guided surgical navigation during complex otologic surgery may improve surgical outcome and decrease morbidity by providing an accurate real-time display of surgical instrumentation relative to patient anatomy and pathology. In select cases, the extra cost of imaging immediately prior to surgery and extra operating room time may be compensated by enhancing the ability to distinguish distorted anatomy relative to disease, potentially improving surgical outcome. IGSN, although useful, does not replace surgical expertise and experience.

Congenital cytomegalovirus infection is the most frequent nongenetic cause of pediatric hearing loss in the United States, affecting approximately 8,000 children each year. Due in part to variable cytomegalic involvement of the auditory cortex, cochlear implantation outcomes have varied widely. Functional magnetic resonance imaging (fMRI) has the potential to assist in determining candidacy for cochlear implantation through the detection of intact auditory pathways including the cortex. We report a case of a 21-month-old girl with cytomegalovirus-related deafness and diffuse white matter involvement in which fMRI was a determining factor for cochlear implantation and side selection.

BACKGROUND: The head and neck is the most common site of mucosal melanoma, a cancer with poor prognosis. In contrast to cutaneous melanoma, mucosal melanoma of the head and neck (MMHN) is uncommon, with limited data regarding outcomes and prognostic factors drawn from small, single-institution case series. In order to identify factors predictive of survival, we analyzed MMHN outcomes in a large US cohort. METHODS: MMHN cases (n = 815) diagnosed in the USA between 1973 and 2007 were analyzed in the Surveillance, Epidemiology, and End Results registry, and cause of death was individually determined in 778 (95.5%) cases. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to analyze prognostic variables. RESULTS: Disease-specific survival status was determined in 778 (95.5%) cases. The 5- and 10-year rates of overall survival (OS) were 25.2 and 12.2%; disease-specific survival (DSS), 32.4 and 19.3%. On multivariable analysis, anatomic primary site was an independent predictor of OS and DSS, with tumors in the nasal cavity and oral cavity associated with survival superior to tumors in the nasopharynx and paranasal sinuses. Age > 70 years, tumor size, nodal status, and distant metastasis status were additional independent predictors of poorer survival. CONCLUSIONS: In this large cohort of patients with MMHN, we have identified several novel factors robustly predictive of overall and melanoma-specific survival.